download the application yourself. - Pinellas County Health ...

FLORIDA BREAST AND CERVICAL CANCER
EARLY DETECTION PROGRAM
BCC Program
Patient Information Form
Women 50 to 64 years old – low income – no insurance
NO COST Mammogram and Pap smear
Phone (727) 824-6917
Legal Last Name: _________________________ Legal First Name: ______________________MI: ______
(per state issued ID)
(per state issued ID)
Social Security Number: ________-________-__________ Date of Birth: _______/______/_______
Month Day Year
Address: ______________________________________ Lot/Apt: ________________________
City: ____________________________ FL, Zip: ________________Best time to call: ____________
Home Phone: _____________________ Work or Cell Phone: _____________________ Sex: Female
Marital Status: Single Married Divorced Separated Widowed
Race: White Black Pacific Islander Asian American Indian
Height (In): _________
Weight (lbs): ___________
Do you have a history of high blood pressure? _________________________________
Primary Language: (If other than English) Spanish Other (specify) _______________________
Are you Hispanic or Latina? Yes No
How did you find out about our program? Local ACS brochure CHD Community Family/ Friend Internet
Dr Office Newspaper Postcard
I, ________________________________ give my permission for the Florida Breast &
Cervical Cancer Early Detection Program to identify me as a client of their program
when they call me at (__) ____________.
I also give permission for the Breast & Cervical Cancer Screening Program to leave
detailed messages at the above phone number for me if needed.
Date: _________________
Signed___________________________________
2